The Rise and Fall of Heart Disease

Heart disease was once the number one killer in rich countries. Maybe it still is. Huge amounts of time and money have gone into trying to reduce it — statins, risk factor measurement (e.g., cholesterol measurement), telling people to “eat healthy” and exercise more, and so on. Unfortunately for the poor souls who follow the advice (e.g., take statins), the advice givers, such as doctors, never make clear how little they know about what causes heart disease. Maybe they don’t realize how little they know.

I encountered an ignorant-without-knowing-it expert after a talk I gave about the effect of butter on brain function. I found that butter improved my brain function (measured by arithmetic speed). I had been eating lots of butter for more than a year. A cardiologist in the audience said I was killing myself. He thought butter caused heart disease. I said that I had experimental data that butter was good for me. Easy to interpret. The notion that butter is bad has come from epidemiological (non-experimental) data, which is hard to interpret. The cardiologist said that the epidemiology has not been misleading. One sign of our correct understanding, he said, is that heart disease has declined. I said there were many possible reasons for the decline.

A 2012 paper called “An epidemic of coronary heart disease” by David Grimes, a British doctor, could hardly make clearer how little we know about the cause of heart disease. Grimes points out that before 1920 heart disease was almost non-existent, that it rose sharply from 1930 to 1970 and since 1970 has declined sharply, at roughly the same rate that it rose. Both the rise and the fall are mysteries, says Grimes, in agreement with what I told the cardiologist. The rise and fall contradict all popular explanations. Heart disease cannot be due to obesity or wealth — both increased substantially at the same time heart disease fell sharply. Nor was the decline due to government intervention:

The decline of CHD deaths in the UK was further described in a UK Government report of 2004, Winning the War on Heart Disease. In this report, the government predictably but undeservedly assumed responsibility for the decline. Clearly, the NHS [National Health Service] in the UK could not have had an international effect [the decline is international].

“There [has been] no obvious effect of statin therapy or other medical intervention,” Grimes continues. Yet statins continue to be prescribed in very high amounts and very great expense. The NNT (number of people you need to treat to save one life) is often in the thousands, he noted.

Those who complain about the high cost of health care fatally fail to grasp this enormous ignorance — about many things, not just heart disease — and its consequences. Reducing the cost of health care (reducing the cost of statins, for example) would improve health if cost were the only thing deeply wrong with our health care system. It isn’t.

I’ve been reading with interest a blog by an economist interested in ancestral health and he has been posting studies showing butter has a negative impact on flow-mediated dilation which he uses as a marker of heart health. Interesting contrasting those studies with your findings of improved brain function and heart exams.

Seth: As far as I know, it hasn’t been established that butter IS bad overall. I think my brain function test can be taken as an overall measure of brain health (because it correlates with several other measures) but I don’t think the same can be said for flow-mediated dilation — that it is a good measure of overall heart health.

About four years ago, I went to a lecture by Dr. Caldwell Esselstyn (cardiologist from the Cleveland Clinic). He argued that all oils & fats are bad for your heart. He advocates an extremely low-fat vegan diet. He showed radiograms showing cardiac arteries before and after his diet. The improvements were substantial.

I don’t know if he’s right or not, and my own diet is not low in fat by any means. But I’m raising this issue because his data was not epidemiological in nature. The cardiac arteries were from the same patient, taken at two different points in time.

He also talked about a test called the Brachial Artery Tourniquet Test, which measures the time it takes for an artery to recover following physical compression of it. Esselstyn claimed that this test can be used to show the harmful effects of eating oils and fats.

Seth: Esselstyn gives convincing evidence that his diet is better than what his subjects were eating before. Of course, his diet is a huge change from what they were eating before. I have no idea what part or parts of that change made a difference. Did his subjects improve because they ate less of Chemical X? Did they improve because they ate more of Chemical Y? There are hundreds of Xs and Ys involved. In contrast, my butter experiment changed one thing (butter). Sure, butter has several parts, but it is not a massive change. And I am not making claims about components of butter.

People in Tibet are known for a diet high in butter. Maybe we could look at their hearts for evidence? Of course we have to consider that over the milennia there have been adaptions for them to this diet.

“Indeed Jake, the curve of CHD and tobacco consumption is almost identical (ramp up to a peak in the 60s/70s, rapid decline since).” That suggests to me that it ain’t tobacco – if it were I’d expect a lag.

If the CHD curve declines just as much for countries where smoking hasn’t declined much, then that would be pretty conclusive disproof. Worth a look?

One of the sources that David Grimes cites in his paper is a NHS report with interesting international data. The charts on page 10 in particular. It looks like Ukraine and Russia are in a totally different league in terms of CHD deaths, with 3-4x the incidence per 100,000 compared to the UK.

Thank you for posting this interesting essay, Seth. It reminds me of Rene Dubos who studied tuberculosis incidence carefully and pointed out that while society in general and the medical profession in particular credited the development of antibiotics with the decline in TB, the decline had actually begun well before antibiotics were in widespread use.

Seth: I didn’t know that, but I see that he makes that point in The White Plague, which I will look at.